Provider Demographics
NPI:1396861134
Name:MCCLARTY, STACEY JACK (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:JACK
Last Name:MCCLARTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11225
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-2225
Mailing Address - Country:US
Mailing Address - Phone:423-892-5602
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:975 E THIRD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-778-7608
Practice Address - Fax:423-778-2360
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD41787207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912136Medicaid
TN3000170Medicaid
TNP00473706OtherMEDICARE RAILROAD
AL009912228Medicaid
GAN394859OtherWELLCARE (GA MEDICAID)
TN4160316OtherBLUE CROSS BLUE SHIELD OF TN
GA762425491AMedicaid
TN4160316OtherBLUE CROSS BLUE SHIELD OF TN
TN3000170Medicare PIN